NPR Story

2:27 pm

Mon January 20, 2014

New Thinking On Women And Alcohol

Alcoholics Anonymous is commonly considered the gold standard for helping people control their drinking problems.

But there’s a growing school of thought that there are problem drinkers who can cut back — as opposed to severely dependent drinkers who must cut out drinking altogether. There are new tools, such as medication and online support.

People are reluctant to seek treatment for it when the condition is mild or moderate.

– Gabrielle Glaser

Severely alcohol-dependent people should consider an abstinence program, Glaser tells Here & Now’s Robin Young, but research has shown there are far more mild to moderate problem drinkers than severe problem drinkers.

“We say, ‘oh if you have a drinking problem, you should be abstinent forever more,’ and not a lot of people want to do that. Not a lot of people what to say to themselves ‘I don’t ever want to have a drink again.’ It’s very frightening. So they don’t enter treatment and they develop worse and worse problems,” Glaser says.

The term ‘alcoholic’ is problematic too, she says, noting that scientists don’t use the term anymore, instead defining an alcohol use disorder on a severity spectrum.

“People are reluctant to seek treatment for it when the condition is mild or moderate, because they think, they believe, the AA narrative that you have to hit bottom. But that’s really just not true, that’s not what the evidence shows. That’s not what you would tell someone who’s eating too much and has rising cholesterol figures. You don’t say ‘hey buddy keep going with those bacon cheeseburgers until you have your first heart attack.’ You intervene when the condition is mild,” she says.

One program that offers an alternative to abstinence is Moderation Management, which recommends taking a 30-day break from drinking, and then using its strategies to change drinking behavior.

More Information & Resources

ModerationManagement.org:Why is a Moderation Program needed? (MM is a “behavioral change program and national support group network for people concerned about their drinking and who desire to make positive lifestyle changes.”)

National Institute on Alcohol Abuse and Alcoholism:Tips to try (One of the nine tips is: “Keep track of how much you drink. Find a way that works for you, carry drinking tracker cards in your wallet, make check marks on a kitchen calendar, or enter notes in a mobile phone notepad or personal digital assistant. Making note of each drink before you drink it may help you slow down when needed.”)

Well have you already failed at your New Year's resolution? Experts say it could be because you've taken an all-or-nothing approach, but that's particularly controversial when it comes to drinking. Abstinence, admitting powerlessness over alcohol and giving it up has long been the only route for members of AA, but there's growing thinking that there are problem drinkers who can cut back, especially since there are new tools, like medication and online support.

And our next guest says women in particular need an alternative to AA because they often already feel powerless. Gabrielle Glaser is author of "Her Best-Kept Secret: Why Women Drink-And How They Can Regain Control." And she joins us from the NPR studios in New York with a look at women and drinking. And Gabrielle, why focus on women?

GABRIELLE GLASER: We know that women are far more likely to be diagnosed with depression and anxiety disorders. They're far more likely to have had eating disorders and to have been sexually abused. And those are four main risk factors for women.

YOUNG: Well, and more and more woman are drinking. You've got some stats: They're being stopped more for drunken driving than they were two decades ago; biggest consumers of wine.

GLASER: Absolutely. They buy about 70 percent of the 800 million gallons of wine sold in the United States every year, and they drink the lion's share of that. They are - middle-aged women are checking in more frequently to alcohol rehab programs, and that's very, very telling because it's very hard for middle-aged women with kids at home to disappear for a month.

YOUNG: Yeah, who will take care of their children, who will run the home? Now again, we understand, and you make it clear, that you understand that there is disagreement with the thinking of using outside tools, tools outside of AA. But also you say that there are some women for whom this does not apply.

GLASER: Absolutely. There are severe alcohol-dependent folks, and these are the people who need a shot of vodka in the morning to maintain, to steady their nerves. They have a flask at work. Of course these people need to be considering only abstinence. But what our epidemiological research shows, and we've spent a lot of money on this as a government, as taxpayers, we have interviewed 85,000 people about their drinking habits.

And what those two studies - one in the early '90s, one in the 2000s - what those studies showed, that among heavy drinkers, problem drinkers, people who are on the moderate to mild end of what's now being called alcohol use disorder, outweigh alcohol-dependent folks four or five to one.

YOUNG: You say these problem drinkers may be starting to drink secretly or planning their drinking or for women drinking more than four days a week or more than three drinks at one time.

GLASER: And those are the people for whom other and different alternatives may be best applied.

YOUNG: Let's take a look at some. You talk about the drugs that we've talked about on the program. Naltrexone, this was approved by the FDA in 1994. It blocks the signals released when consuming alcohol so you don't, what, get the mental benefits, the rewards from it.

GLASER: Right.

YOUNG: But you say that even Naltrexone is being used in a different way than many American doctors use it.

GLASER: Absolutely. American doctors prescribe it in general with the goal of abstinence. So they tell people, you know, take this drug, it's going to block your opioid receptors. You're not going to feel pleasure when you drink, but don't drink. And in Finland, where the national health care system implements a single program that they have found to be most effective, it's given with the prescription of you should take this an hour before you drink and then drink. And it's - the drug has been shown in many, many peer-reviewed clinical trials to be more effective when used that way.

YOUNG: The cravings diminish.

GLASER: The cravings diminish. The behavior becomes extinguished because the alcohol is doing nothing for you. It's not bringing you any reward.

YOUNG: Well, and this program that you write about in Finland is actually run by an American, John David Sinclair. His approach he called pharmacological extinction, the pharmaceuticals again make your cravings extinct. He claims that, and he claims success with that.

What are some other programs in particular that you find successful for women?

GLASER: Well, there's one called moderation management, which has been around for about 20 years, and it encourages people, again not people who are alcohol dependent but people who have found that their control is slipping away a little bit, they used to have two drinks, now it's three, maybe it's four, and I'm not saying that oh, that's a great way to drink, I'm simply saying, and the research will tell, that that's not what is technically classified as alcohol dependence.

So what moderation management suggests is that you take a 30-day break from drinking, and then you apply cognitive behavioral tools. You can get those online. You can get those in groups. You can get - and moderation management is free. And you apply those to yourself, and they reinforce what your thoughts are and your beliefs are about how you're drinking.

YOUNG: OK, a couple thoughts. If you can't do the 30 days without drinking, then you have a far more serious problem.

GLASER: Right, then you have a far more serious problem. If you can't even get through that 30 days, then of course moderation management is not for you.

YOUNG: So with that in mind, we'll link listeners to both the AA and moderation management websites. And at the latter, you can link to a government site with tips like drinking tracking cards you can keep in your wallet or measures to see real drink sizes. Hint, a coffee mug of wine is not one drink, it's more likely two.

Our guest is author Gabrielle Glaser, who by the way says she has no dog in this hunt, she's just dug into the research. What say you? Let us know your thoughts on cutting back instead of quitting at hereandnow.org. You're listening to HERE AND NOW.

(SOUNDBITE OF MUSIC)

YOUNG: It's HERE AND NOW, continuing our conversation with author Gabrielle Glaser about women and drinking. Her recent op-ed in the New York Times reignited a debate. It's titled "Cold Turkey Isn't the Only Route." She describes alternative to the AA model of abstinence, something very controversial, especially to loved ones of alcoholics who have been on the receiving end of the heartbreak and abuse they can dish out.

But Gabrielle says there's a distinction between dependent drinkers who can't stop and problem drinkers who are seeing their drinking creep up beyond four days a week and who outnumber dependent drinkers by four or five to one. One idea for them, she says, is reducing harm. So for instance, in Amsterdam officials are paying alcoholics with beers to clean up a park, and that's actually reducing how much they drink.

Another program, it's actually a movement, Moderation Management, a free online program with steps just like AA and support groups, but it's about cutting back on drinking, not quitting. And Gabrielle, as you well know, there's a doctor involved but the civilian founder of Moderation Management is Audrey Kishline. She left the program, said it didn't work for her. Thirty percent leave for the same reason.

She joined AA but then got drunk and killed a father and daughter in a traffic accident.

GLASER: Well, but remember, she had joined AA. She left Moderation Management. She put a note on her website in January of 2000 saying she was not a candidate for moderation, it wasn't working for her, and that she was leaving to join abstinence-only groups. She joined AA, and two months later, clearly abstinence was not working for her either because that's when she got really loaded and drove the wrong way on an icy highway in eastern Washington and killed that man and his daughter.

And it's incredibly tragic, but she was a candidate, obviously, for someone who should have stayed away from alcohol altogether. And a lot of this, what science calls low-risk drinking or a return to low-risk drinking, is something that you need to decide for yourself, and clearly she had decided that in January - hey, this isn't working for me. But neither was the notion of powerlessness over alcohol.

YOUNG: It sounds like, as you say, someone who really, really needed abstinence. Well, but for those for whom self-moderation seems to be working, moderateddrinking.com, what happens there?

GLASER: That is an app, a computer-based, Web-based app that allows people to track their drinking. It allows people to kind of have this mindful drinking that you mentioned earlier. And what it also allows people to do is a sort of cost-benefit analysis. Where does my drinking become a problem for me?

And it allows people to see that in black and white. And women especially, more than two-thirds of the users of that app, happen to be women, and this is an app that has been shown in two very well-regarded peer-reviewed journals to have great success in reducing the number of drinking days.

Reducing the number of drinking days is something again that's kind of anathema in our country. We say, oh, if you have a drinking problem, you should be abstinent forever more, and not a lot of people want to do that. Not a lot of people want to say to themselves, hey, I don't ever want to have a drink again. It's very frightening. So they don't enter treatment, and they develop worse and worse problems.

YOUNG: They do nothing.

GLASER: Exactly. And these programs, there's another one called I Self Change, you can download it on the iTunes store, these programs allow people to do this within the privacy of their own home. There's no stigma of going out and saying, hey, I'm an alcoholic. I think that word should be retired from our lexicon anyway, but that's just my two cents.

YOUNG: Because why? You point out alcoholism is a disease, and we don't force people to sit in rooms and say I'm an asthmatic.

GLASER: Right, but the word alcoholic and alcoholism is something that was promulgated by AA itself. And we've lumped together anyone with a drinking problem into that same rubric. Oh, well, they're an alcoholic. And actually, even scientists don't use that word anymore.

The term now in the DSM-V is alcohol use disorder, which encompasses a spectrum from mild to moderate to severe dependence.

YOUNG: DSM is?

GLASER: The Diagnostic and Statistical Manual of Mental Disorders. And in 1994, the DSM-IV came out with alcohol abuse and dependence. So alcoholism has not really been something that scientists have used for 20 years.

YOUNG: Well, and as you say, the main tool hasn't changed since 1935. Time to get some new ones. People can hear this and make their own decisions, but you know, I'm sure you've gotten reaction to the op-ed, people who are furious, have lost loved ones to alcohol, and they don't want to hear about a route that might give an alcoholic - still use that word - an exit.

GLASER: Right, which is actually tragic, because if you liken it, say, to depression - 30, 40 years ago, before Prozac hit the scene, we really had very few tools to take care of people who were severely depressed. If they were a threat to themselves and others, someone in their family could commit them, and they had electroconvulsive shock therapy in a hospital. They were sedated around the clock, and then eventually they were let out as very different people.

Nobody wanted to get treatment for depression because it was horrible. It was barbaric. And likewise with alcohol use disorder, people are reluctant to seek treatment for it when the condition is mild or moderate because they think, they believe the AA narrative, which says you have to hit bottom.

But that's really just not true, that's not what the evidence shows. That's not what you would tell somebody who's eating too much and has rising cholesterol figures. You don't say, hey, buddy keep going with those bacon cheeseburgers until you have your first heart attack. You intervene when the condition is mild.

YOUNG: Well, and we mentioned what the criticism is going to be and is, but I can also hear loved ones of people with alcohol disorder saying I'd give anything for them to reduce their drinking to maybe two days a week.

GLASER: Absolutely, and that's a harm reduction technique. And we need to offer different tools that have been shown to be so effective elsewhere. And in Canada, for example, harm reduction is offered as - and harm reduction is a series of strategies that allow people with negative behaviors to reduce the negative consequences of those unhealthy behaviors.

So the first one that comes to mind is needle exchange. The second one that comes to mind in terms of drinking is never drinking and driving, or drinking and setting a limit for yourself. This might sound like an enormous amount of alcohol to you and me, but never drinking more than four drinks.

If I had four drinks, I'd be on the floor, but some people have a high tolerance, and they schedule two days a month in which they can do that. And is it super-healthy? I'm not going to be the judge of that. Is it super-healthy if they don't drive? You bet it's a lot healthier if they don't drive.

YOUNG: And is it better than four drinks every day for the month?

GLASER: Exactly, exactly, exactly.

YOUNG: That's Gabrielle Glaser, journalist and author of "Her Best-Kept Secret: Why Women Drink-And How They Can Regain Control," on some of the new and controversial thinking in some quarters about drinking. Gabrielle, thanks so much.

GLASER: Thank you so much for having me.

YOUNG: So your thoughts. Are you surprised a problem drinker is more than three drinks a day or four days a week? Let us know. Weigh in at hereandnow.org. You're listening to HERE AND NOW. Transcript provided by NPR, Copyright NPR.